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179543 11/24/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1 ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CARMEL, INDIANA 46032 DEVELOPMENTATTN: ACCT RECV CHECK AMOUNT: $10,669.97 101 N SENATE AVE CHECK NUMBER: 179543 INDIANAPOLIS IN 46206 -0847 CHECK DATE: 11/24/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1120 4110000 1,560.00 FULL TIME REGULAR 1125 4110000 4,414.97 FULL TIME REGULAR 1201 4110000 1,560.00 FULL TIME REGULAR 1207 4110000 1,623.00 FULL TIME REGULAR 651 5023990 1,512.00 OTHER EXPENSES 133438 -1 INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277 Toll free 1- 800.891 -6499 Marion County 232 -7436 STATEMENT OF BENEFIT CHARGES (FORM 535) CONFIDENTIAL RECORD PURSUANT TO IC 22.4 -19 -6, IC 4 -1 -66 Page 1 CITY OF CARMEL ACCOUNT/ ATTN CLERK TREASURER LOCATION NUMBER 133438 -000 ONE CIVIC SQ REPORTING MONTH OCT, 2009 CARMEL IN 46052 -2584 NETCHARGES $10,669.97 POSTING DATE NOV 2009 The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for unemployment insurance since, before any payments were made the employer had the opportunity and the responsibility to report any information'Which could disqualify the claimant. SOCIAL I BENEFIT PAID FOR SECURITY YEAR END I CLAIM WEEK AMOUNT NUMBER EMPLOYE NAME DATE LEVEL DATE I ENDING I ACQ CHARGED THIS IS NOT A BILL OR A REQUEST FOR MONEY DUE TO THIS DEPARTMENT. It is a statement of benefit charges made to your account during the "reporting" month, At the end of the "posting" month, you will receive a Reimbursable Bill (Form 1067) for these charges and any previous liability still outstanding. NEW CHARGES FOR THE REPORTING MONTH 10/09 4 E 0 EDEDUWA 07/25/09 EB 10/25/09 10/17/09 97.50 E 0 EDEDUWA 07/25/09 EB 10/25/09 10/24/09 97.50 3 02 7 D M JENSEN 08/28/10 REG 10/15/09 09/19/09 390.00 2 D M JENSEN 08/28/10 REG 10/15/09 09/26/09 390.00 a 2 D M JENSEN 08/28/10 REG 10/15/09 10/03/09 390.00 D M JENSEN 08/28/10 REG 10/15/09 10/10/09 390.00 D M JENSEN 08/28/10 REG 10/26/09 10/17/09 390.00 D M JENSEN 08/28/10 REG 10/30/09 10/24/09 390.00 D L LLOYD 00/25/10 REG 10/14/09 10/10/09 128.00 D L LLOYD 09/25/10 REG 10/21/09 10/17/09 128. 00 D L LLOYD 09/25/10 REG 10/26/09 10/24/09 Iv 1 128.00 R K PETE 07/03/10 REG 10/12/09 10/10/09 I 51.56 R K PETE 07/03/10 REG 10/19/09 10/17/09 74.93 M A MONTGOMERY 08/14/10 REG 10/05/09 10/03/09 357.00 M A MONTGOMERY 08/14/10 REG 10/11/09 10/10/09 357.00 M A.MONTGOMERY 08/14/10 REG 10/19/09 10/17/09 0\ 357.00 M A MONTGOMERY 08/14/10 REG 10/26/09 10/24/09 357.00 D M LINGELBAUGH 09/18/10 REG 10/05/09 10/03/09 390.00 D M LINGELBAUGH 09118110 REG 10/11/09 1 ,fJ 390.00 D.M LINGELBAUGH 09/18/10 REG 10/18/09 10/17/09 390.00 D M LINGELBAUGH 09/18/10 REG 10/25/09 10/24/09 390.00 C M BRODERICK 04/04/09 EB 10/06/09 10/03/09 r 39fl.00 I r C M BRODERICK 04/04/09 EB 10/12/09 10/10/09 390.D0 C M BRODERICK 04/04/09 EB 10/20/09 10/17/09 390.D0 0_�� C M BRODERICK 04/04/09 EB 10/27/09 10/24/09 390.00 J L HOPE 08/14/10 REG 10/08/09 10/03/09 390.00 J L HOPE 06'/14/10 REG 10/14/09 10/10/09 390.00 J L HOPE 06 /14/10 REG 10/21/09 10/17/09 390.00 J L HOPE 08/14/10 REG 10/28/09 10/24/09 390..00 CONTINUE ON NEXT PAGE An in the ACID column denotes a charge resulting from an acquisition of another business. Accour!t /Location Number: 133438 —000 Reporting Month: OCTOBER, 2009 Page 2 ;Employer Name: CITY OF CARMEL SOCIAL BENEFIT PAID FOR SECURITY YEAR END CLAIM WEEK AMOUNT NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED RGES FOR THE REPORTING MONTH 10/09 E SWIRSKY 07/24/10 REG 10/27/09 10/17/09 4.48 o J G KOZLOVICH JR 06/05/10 REG 10/04/09 10/03/09 378.00 J G KOZLOVICH JR 06/05/10 REG 10/12/09 10/10/09 1 378.00 6 J G KOZLOVICH JR 06/05/10 REG 10/18/09 10/17/09 378.00' J G KOZLOVICH JR 06/05/10 REG 10/26/09 10/24/09 378.00 TOTAL NEW CHARGES FOR THE REPORTING MONTH 10/09 10,669.97 TOTAL AMOUNT OF NET CHARGES 10,669.97 END OF BENEFIT CHARGE STATEMENT o'D c2 I��o.i✓� 1176% I� I a o.oU 4'. An in the ACQ column denotes a charge resulting from an acquisition of another business. VOUCHER NO. WARRANT N ALLOWED 20 Indiana Department of Workforce Development ti IN SUM OF 10 North Senate Avenue Indianapolis, IN 46204 $1,560.00 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members 1120 41- 100.00 $1,560.00 1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except NOV 2 3 2009 IJ Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER CITY Or CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) $1,560.00 I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6 20 Clerk- Treasurer 'VOUCHER 096770 WARRANT ALLOWED 146500 IN SUM OF IN DEPT OF WORKFORCE DEVEL. Benefit Administration 10 N. Senate Avenue Indianapolis, IN 46204 Carmel Wastewater Utility y ON ACCOUNT OF APPROPRIATION FOR Board members i PO INV ACCT AMOUNT Audit Trail Code 1009 01- 4080 -12 $1,512.00 Voucher Total $1,512.00 Cost distribution ledger classification if claim paid under vehicle highway fund Prescribed by State Board of Accounts City Form No. 201 (Rev 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show, kind of service, where performed, dates of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee 146500 IN DEPT OF WORKFORCE DEVEL. Purchase Order No.� Benefit Administration Terms 10 N. Senate Avenue Due Date 11/17/2009 Indianapolis, IN 46204 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 11/17/2004 1009 $1,512.00 I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6 i� fi Cam. -•-�'f ��1 Date Officer ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms 146500 Indiana Dept. of Workforce Development Date Due 10 North Senate Ave., SE106 Indianapolis, IN 46204 -2277 Invoice invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 4,414.97 11!9109 133438 Benefit charge Oct'09 PPl!, ALL 'OUT, OF 101 `per Nllchael 1,1120I0�8 �s Total 4,414.97 I hereby certify that the attached i cr bills) is (are) true and correct and have audited same in accordance with IC 5- 11- 10 -1.6 1 20 Clerk- Treasurer Voucher No. Warrant No. 146500 Indiana Dept. of Workforce Development Allowed 20 10 North Senate Ave., SE106 Indianapolis, IN 46204 -2277 In Sum of 4,414.97 ON ACCOUNT OF APPROPRIATION FOR 101 General Fund PO# or INVOICE NO. ACCT 1 AMOUNT Board Members Dept TITLE 1125 133438. 4110000 4,414.97 1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except 19 -Nov 2009 Signature 4,414.97 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 207 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, 7 number of units, price per unit, etc. Payee (dux, ,p f testa Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO.� z� �q WARRANT NO. ALLOWED 20 �a� 4� \�,,a�� IN SUM OF ON ACCOUNT OF APPROPRIATION FOR 1 2 J Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except 20 8ignat e Title Cost distribution ledger classification if claim paid motor vehicle highway fund J Prescr& by Slate Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee 1 J, a/2p (L.)6 �1 C Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total a, 66 1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF ON ACCOUNT OF APPROPRIATION FOR Board Members Po# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or d 7 �crc� bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except X- f©�! jo 20 Signature Cost distribution ledger classification if Ti claim paid motor vehicle highway fund